Clinical documentation system for use by multiple caregivers

ABSTRACT

A computer-based system for recording, storing, and accessing clinical documentation in an acute care setting is provided. In an embodiment of the invention, a single electronic database or repository for storing clinical patient notes, provides multiple points of read/write access via a user interface operating on one or more client computers that are in real-time communication with the repository.

This application is a continuation of U.S. application Ser. No.09/950,158 filed Sep. 10, 2001, which application claims priority toU.S. Provisional Application Ser. No. 60/233,950, filed Sep. 20, 2000,the disclosure of which is hereby expressly incorporated herein byreference.

FIELD OF THE INVENTION

The invention relates generally to information management systems foruse within the healthcare enterprise, and more particularly, to a systemfor documenting clinical patient information generated by multiplecaregivers.

BACKGROUND OF THE INVENTION

During the course of a patient's stay in an inpatient or acute carefacility, the patient will be seen by a variety of health care providersas they review the patient's status, recommend treatments and protocols,provide care, order tests, etc. Providers must record all of theiractivities and decisions for the patient, and efficient communication ofthis information between all of a patient's caregivers is key to theproblem of providing a patient with the best possible care.

Existing approaches to this problem typically center on some kind ofshared patient record. A shared paper chart kept in or near thepatient's room represents perhaps the most common but also the leasteffective approach. A shared paper chart offers very limited securityand virtually no simultaneous access for either viewing or editing thepatient's hospital record. What's more, as information is eventuallyadded to the patient's record from a large number of caregivers, itbecomes increasingly difficult and time consuming to identify and reviewappropriate information for a particular situation.

A computer-based approach can solve some of these problems by providinga central repository for storing and accessing clinical documentationfor a patient, and in recent years many computer-based clinicaldocumentation systems have been conceived and implemented for bothambulatory and acute care settings. However, these systems typicallydemonstrate weaknesses and problems that result in a failure to ensureefficient communication between a patient's acute caregivers. Problemswith these systems include a failure to address one or more of thefollowing needs:

providing a single point of access to the information recorded by all ofthe patient's caregivers during an acute care episode;

providing simultaneous access to a patient's chart for both viewing andediting from different locations while maintaining data integrity;

providing role-based security to limit each caregiver's viewing andediting access to a patient's chart;

providing user-linked time-stamps for both data entry and review that a)make it easy to present a longitudinal view of the patient record, b)provide a means for a user to quickly see information that's been addedto the patient's record since the user's last review, and c) providingfor note cosign by one or more caregivers;

providing for storing and sorting patient notes according to caregiver'sroles, service areas and etc.;

providing easy to use filter and search tools that allow a caregiver toquickly identify and review clinically appropriate information for agiven situation;

providing for entering data other than entirely manual keyboard entry,for example automated text-entry options, dictation, voice recognition,etc.;

providing for incorporating available information relevant to apatient's acute care episode, for example emergency room (ER) notes,hospital discharge summaries etc.

Thus, there is a need for a clinical documentation system that addressesthese needs within the healthcare enterprise.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a block diagram illustrating a patient health record system inaccordance with an embodiment of the invention.

FIG. 2 is a block diagram illustrating a graphic user interface of thepatient health record system illustrated in FIG. 1.

FIG. 3 is a graphic representation of the graphic user interfaceillustrated in FIG. 2.

FIG. 4 is a graphic representation of a new/edit window function inaccordance with an embodiment of the invention.

FIG. 5 is a graphic representation of a cosign function in accordancewith an embodiment of the invention.

FIG. 6 is a graphic representation of a filter function in accordancewith a preferred embodiment of the invention.

FIG. 7 is a flowchart representing the general workflow associated witha system in accordance with an embodiment of the invention.

FIG. 8 is a flowchart representing a workflow for adding, editing ordeleting a patient note in accordance with an embodiment of theinvention.

FIG. 9 is a flowchart representing a workflow for addending a patientnote in accordance with an embodiment of the invention.

FIG. 10 is a flowchart representing a workflow for filtering patientnotes in accordance with an embodiment of the invention.

FIG. 11 is a flowchart representing a workflow for retrieving anddisplaying a last entered patient note in accordance with an embodimentof the invention.

FIG. 12 is a flowchart representing a workflow for searching patientnotes in accordance with an embodiment of the invention.

FIG. 13 is a flowchart representing a workflow for annotating a patientnote in accordance with an embodiment of the invention.

FIG. 14 is a flowchart representing a workflow for sorting patient notesin accordance with an embodiment of the invention.

FIG. 15 is a flowchart representing a workflow for cosigning a patientnote in accordance with an embodiment of the invention.

FIG. 16 is a flowchart representing a workflow for printing and/orcopying a patient note in accordance with an embodiment of theinvention.

DETAILED DESCRIPTION OF THE INVENTION

A computer-based system for recording, storing, and accessing clinicaldocumentation in an acute care setting is provided. In an embodiment ofthe invention, a single electronic database or repository for storingclinical patient notes is accessed via a plurality of clientworkstations coupled, e.g., networked, to the single electronic databaseproviding multiple points of read/write access via a user interfaceoperating on one or more client computers that are in real-timecommunication with the repository.

The system may provide for storing and sorting patient notes accordingto caregiver's roles, service areas, etc., and may include a data accessscheme that provides simultaneous view access to a patient's chart forboth viewing and editing, and which automatically locks an individualnote from write access when it is being edited by someone else. Inaddition, an embodiment of the invention may include a role-baseduser-security scheme that can be configured to limit each caregiver'sviewing and editing access to a patient's chart to only appropriatetypes of information. An embodiment of the invention may also include auser-linked time-stamping mechanism for both data review and entry and acorresponding user interface that a) presents a longitudinal view of thepatient record and b) permits a user to easily filter for informationthat's been added to the patient's record since the user's last review.Longitudinal view refers to an ability to display and view notes from apatient's previous contacts over time providing essentially a holisticview of the patient's contact history.

An additional embodiment of the invention may provide for importing(either manually or automatically) available information relevant to apatient's acute care episode from external sources where necessary, forexample ER notes, hospital discharge summaries, etc., and for viewing,filtering, and searching this information along with the other patientnotes. Still further, an embodiment of the invention may provide forimporting, storing and viewing graphic and other multi-media informationand linking it to the appropriate entries in a patient's acute carerecord.

A system according to the embodiments of the invention may include auser interface coupled to the enterprise health record system to providesingle point of access for information recorded by all of a patient'scaregivers during an acute care episode. The user interface may includepre-defined role-based filters and/or an easy to use custom filter andsearch options that allow a caregiver to quickly identify and reviewclinically appropriate information for a given situation. The userinterface allows caregivers to choose between a number of data entryoptions, including manual keyboard entry, automated text-entry,dictation, voice recognition, etc. The user interface may also allowcaregivers to file a note (to store it on the server) and mark it eitheras complete or pending, and may further allow a caregiver to edit a notewhile also reviewing other information in the patient's acute carerecord. In accordance with the embodiments of the invention, the userinterface makes it easy for users to take appropriate follow up actionsfor specific entries in a patient's acute care record, for example, fora supervising physician to review, document, and cosign an entry made bya resident.

Referring to FIG. 1, an enterprise patient health record system 10includes a number of data elements 12 for supporting the informationneeds of the healthcare enterprise. As shown in FIG. 1, the system 10includes a patient ID element 14, a patient encounter element 16, aclinical notes element 18, a user security element 20 and a providerselement 22. These elements, for example, provide to the system 10respective data services. For example, the patient ID 14 includes a datastructure for organizing and storing patient identification informationand may incorporate processing and communication capability to allow theelement to interface with the other elements of system 10 for receiving,organizing and storing patient information and for retrieving anddelivering patient information. Of course the processing andcommunication capability may be centralized within the system 10, inwhich case the respective element would include just the appropriatedata structure for organizing and retaining data. The system 10 drives agraphic user interface (GUI) 24 shown in FIG. 2. The GUI 24 may besupported on any number of client workstations coupled, e.g., networked,to the system 10. As such, a user may log into the system 10 at any ofthe workstations from virtually any location, including remotely fromthe healthcare facility via a private network or a public network, e.g.,the Internet.

The GUI 24 may have a web browser or other suitable appearance, andincludes an activity header 26, an activity toolbar 28, a notes toolbar30, a notes listing window 32 and a notes viewing window 34. Theactivity header 26 may provide current patient information, such aspatient name, sex, age, insurance and other patient demographicinformation. The activity toolbar 28 contains point-and-click activityselections, which allow the user to activate various activities withinthe system 10, including the patient's notes activity.

Referring generally to FIG. 3, the notes listing window 32 provides theuser with a listing of all or selectively filtered notes for the currentpatient. Selecting a note from the listing window 32 causes the note tobe displayed in the notes viewing window 34. Notes within the listingwindow 32 may be color coded and/or may include a graphicrepresentation, e.g., an icon, to depict the author, author type,medical service, etc., associated with the note. The author, authortype, medical service, note time and date, etc., may be depicted withthe body of the note in the viewing window 34. Additionally, scrollingmay be provided to facilitate viewing of the notes within the viewingwindow 34.

With more particular reference to FIG. 3, the notes listing window 32may include a plurality of note tabs 36 indicating various categories ofnotes. The user may click on one of the tabs to display a list of notesfor that category. Only the notes written by authors that match acurrent filter criteria, described more fully below, are displayed. Thenotes listing window also includes an author symbol column 38. Withinthe author symbol column 38, a graphic representation, i.e., an icon orsymbol, may be displayed indicating the author type. The notes listingwindow also includes an author segment 40 to display the name of theprovider who wrote the note, the service segment 42 to display the nameof the medical service to which that user belongs and an author typesegment 44 indicating the role of the provider writing the note. Thespecific authors types listed may be configured by a systemadministrator and/or by the user. A cosign segment 46 displays the word“required” for notes requiring a cosign. When a cosign is required, acosign button (not depicted) appears adjacent the note in the listingwindow 32. The cosign button opens a cosign window (FIG. 5) to allow thecosigning user(s) to enter the required cosign(s). A filed segment 48displays the date and time the note was accepted., and a categorysegment 50 indicates the category of the note when all notes are beingdisplayed. In addition, a copy button 54 appears adjacent each note inthe viewing window 34. The copy button 54 causes a copy of the text ofthe note to be copied to a clipboard, e.g., the Windows clipboard,allowing the text to be pasted into a new note and/or into a differentapplication.

Within the notes toolbar 30 there are a number of buttons 52corresponding to functions related to the patient's notes activityallowing the user to select a particular function using apoint-and-click or similar action. New note and edit note functions eachopens a new/edit note window 56 shown in FIG. 4 and allows the user toenter the new note or edit the pending note. The edit notes function mayonly be used with the user's own notes, and the user is not permitted toedit another user's notes. Moreover, once a note is accepted, itgenerally may not be edited or deleted. The window 56 includes a numberof fields including a cosign required box 58, which allows the user toindicate whether a cosign for the note will be required. A note typeselection 60 is provided to allow the user to enter the category of thenote, such as: progress notes, consult notes, procedures, History andPhysical notes, Discharge summaries and Emergency Department notes.

Another note type that may be provided is referred to as a “tagged”note. A tagged note may generally be any note type supported by thesystem 10, but the tagged note includes tag data. The tag datasub-classifies or sub-types the note. One feature of the tag data isthat it allows the notes to be efficiently segregated and collected forreport generation. For example, certain notes may relate only to casualor general comments that would not ordinarily by reported. These notesmight be tagged “casual comments.” Other notes may relate to thepatient's treatment plan that would be reported. These notes might betagged “treatment plan.” A filter search by author would retrieve boththe casual comments and the treatment plan notes, while a search byauthor and the “treatment plan” tag would provide only those notes bythat author that are also tagged “treatment plan.”

The user enters the note text in a note text box 62. Note text may beentered using many common wordprocessing functions including typing,copying, cutting and pasting, by using drafting assist tools, such asthe SmartSet documentation tool available from Epic Systems Corporationof Madison, Wis., or by dictation, which may include voice recognition.The user selects the entry method using the appropriate one of thebuttons 59. Using dictation alone causes the note to be recorded forlater transcription to text, while using dictation in conjunction withvoice recognition may provide an instantaneous text transcription. Anote editing toolbar 64 provides text editing and formatting functionsto assist the user in entering the note text.

When a cosign is required, the cosigning user opens a cosign note window66 shown in FIG. 5 using the cosign button 52 (FIG. 3). The type ofcosign required is specified by cosign data specified for the note bythe author. The required cosign may specify a single caregiver, forexample, the author's attending physician. Alternatively, the requiredcosign may specify cosigns from multiple caregivers from one or moremedical services. The cosign window 66 allows the cosigning user(s) toindicate that the user's note has been reviewed and approved by thecosigner. The user's note is displayed in a note text window 68, and thecosigning user(s) enters their approval/disapproval and any appropriatecomments in a cosign text box 70. Once the cosigning user(s) accepts thecosign note, the original note and the cosign note are linked so otherusers may easily see relevant information from both.

A delete note function allows the user to delete the pending note. Theuser may not delete another user's notes nor may the user delete a noteonce it has been accepted; however, it may be possible to soft delete anote. There may be an occasion that a note should be deleted, forexample, if the note is out of date or in error. In some instances,governmental regulations may prohibit deleting of information from thepatient's record. Soft deleting allows the user to indicate the deletedstatus of the note while not permanently removing the note from thesystem.

A filter function allows the user to modify the types of notes thatappear in the notes listing window and opens a filter options window 72shown in FIG. 6. There are many possible filter criteria that may beimplemented. For example, notes may be filtered by time, author type,author, medical service, etc. For example, selecting to filter by authortype causes a listing of the various author types 74 to appear in thefilter options window 72. The user selects a particular author type,such as physician, registered nurse, etc., and after the user acceptsthe criteria, the notes for that author type are displayed in thelisting window 32.

A “my last note” function causes the user's most recent note in thecategory to be highlighted. A search function opens a find window (notdepicted), in which the user may enter specific words or phrases ascriteria to search within the existing notes. The search may be limitedto a category of notes, or may encompass multiple categories or allnotes.

A legend/notes function toggles the notes listing window 32 between anotes state and legend state. In the notes state, displayed within thelisting window 32 is a listing of the filtered notes for the currentpatient in reverse chronology order. In the legend state, displayedwithin the listing window 32 is a key explaining the symbols and colorsassociated with the notes. As described above, to distinguish notes, bytype, author or otherwise, the notes may be displayed in correspondingcolors and/or may include a graphic representation, e.g., an icon,adjacent the note to designate, for example, its author type, and thelegend state permits viewing of this representative information.

A refresh function updates the information displayed in the noteslisting window 32. If other users have written notes for the currentpatient since the last refresh, these new notes will now appear in thelisting window 32. If a filter option has been selected, the listing isrefreshed using the current filter criteria. In addition, theinformation displayed in the notes listing window 32 may periodically beupdated at a rate specified by a system administrator and/or by theuser.

A print function causes the selected note to be printed. As an option,the user may select to print all of the notes by selecting an all notesfunction associated with the print button.

Referring now to FIGS. 7-15, and initially to FIG. 7, workflowsassociated with the operation of the system 10 are described in greaterdetail. Workflow 700 begins with a logged in user opening an availablepatient record, 701. The system 10 checks the user's security record forauthorized activities, and displays the authorized activities in theactivity bar 28, 703. If the user is not authorized to view patientnotes, 705, then the notes option is not made available to the user viathe activity bar 28, 707. Otherwise, the user selects the patient'snotes activity from the activity bar 28, 709, and the system checks theuser's security to determine the notes the user may access, 711, andthese notes are displayed in the listing window 32, 713. The user maythen add, edit, filter, search, cosign, etc. notes by selecting suchfunctions from the appropriate one of the notes toolbar, 715, the noteslisting window, 717 or the notes display window, 719. Links, 721-741,take the user to a workflow corresponding to the selected activity.

From link 721 for the new/edit/delete functions, the workflow 700proceeds to the workflow 800 illustrated in FIG. 8. If the user wants todelete a note, 801, the user selects the note to be deleted and clicks aDelete button, 803. The system 10 updates the notes listing, removingthe deleted note from all tabs on which it was displayed, 805. If theuser wants to edit a note, 807, the users selects an Edit Note buttonopening the new/edit note window 56, 811. Similarly, if the user wantsto create a note, 809, the user selects a New Note button opening thenew/edit note window 56, 811. The user has several options forcreating/editing a patient note, as described above. Once the note iscreated/edited, the user clicks a Pend button to close the new/edit notewindow 56 and save the note under a pending notes tab. Notes that havenot been accepted may be saved under the pending notes tab of thenew/edit notes window 56. Other users may not view pending notes and theuser may edit or delete the note until it has been accepted. If the userwants to accept the note, the user clicks an Accept button to close thenew/edit notes window 56 and save the note. Once the note is accepted,it cannot be edited and may only be soft deleted. There is also a Cancelbutton allowing the user to cancel out of the new/edit notes windowwithout saving changes.

From the link 723 for the note addendum function, the workflow 700proceeds to the workflow 900 illustrated in FIG. 9. If the user wants tocreate an addendum to a note, the user selects the note and selects theaddendum function opening the new/edit note window 56, 901. Because anote cannot be edited and only may be soft deleted once accepted, addingan addendum provides for adding or updating note information. Editing ofthe addendum is the same as that for editing or creating a note, exceptthat the original text of the note may not be edited, 903. Whencompleted, the user accepts the addendum, and the new addended versionof the note appears in the notes listing window 32 with a date and timestamp link to the original note, 905.

From the link 725 for the note filter function or the link 737 for thenote filter tab, the workflow 700 proceeds to the workflow 1000illustrated in FIG. 10. If the user selects the filter tab, 1001, fromthe notes listing window 32, the system 10 updates the notes listing toinclude only those notes associated with the category indicated on theselected tab in reverse chronological order, 1003. If the user selectsthe filter button, 1001, the filter window 72 is opened, 1005, allowingthe user to set filter criteria, 1007. Filter criteria includes, but isnot limited to, filter by time, filter by author type, all notes,unselect all, reload filter preferences, save filter preferences, acceptor cancel. Filter by time options include filtering by time periods suchas the previous 24 or 48 hours, since last note entry or all notes. Theselect all allows the user to select all author types, and the unselectall allows the user to unselect all author types. The user may createpreferred filter configurations, and these preferences may be saved inconnection with the user profile. This permits the user to easily filterand view the notes most commonly associated with their work activity.Accepting the filter selections returns the user to the notes window 29.

From the link 727 for the “my last note” function, the workflow 700proceeds to the workflow 1100 illustrated in FIG. 11. If the userselects the “my last note” button, 1101, the system 10 automaticallyhighlights the most recent note authored by the user, 1103. The noteslisting is scrolled as necessary to permit display of the user's lastnote.

From the link 729 for the search function, the workflow 700 proceeds tothe workflow 1200 illustrated in FIG. 12. If the user selects the searchbutton, 1201, a find window (not depicted) is opened, 1203. Within thefind window, the user may set search criteria, 1205. The search criteriamay include text that is to be whole or partial word searched within thetext of the notes, including matching case. The search direction can beset between chronological in ascending or descending order. Once a notemeeting the criteria is found, it is highlighted in the notes listingwindow 32. Using a next button, the user may move to the next notemeeting the search criteria. To exit the search function, the userpresses a cancel button.

From the link 731 for the legend/notes function, the workflow 700proceeds to the workflow 1300 illustrated in FIG. 13. If the userselects the refresh button, 1301, the system 10 refreshes the listing ofnotes in the notes listing window 32, 1303. If the user selects the timemark button, 1305, all notes displayed for the patient are marked asviewed by the user as of that current date and time. This time mark datais stored within the system 10, and is available for use in conjunctionwith decision support tools (e.g., has an urgent note regarding thepatient been reviewed within the last 24 hour period). If the userselects the legend button, 1309, the notes listing in the notes listingwindow 32 is replaced with a legend showing the symbols associated witheach author type, 1311. When the user selects the notes button, 1313,the notes listing window 32 toggles back to the notes listing, 1315.

From the link 735 for the notes listing column function, the workflow700 proceeds to the workflow 1400 illustrated in FIG. 14. Upon selectingthe notes listing column function, the notes listing in the noteslisting window 32 is re-sorted in ascending or descending order on thebasis of the information listed in the selected column, 1401. Sorting isin alphabetical or numerical order depending on the type of informationin the column. The user can click the column again to reverse the sortorder from ascending to descending, or vice versa.

From the link 739 for the cosign function, the workflow 700 proceeds tothe workflow 1500 illustrated in FIG. 15. Upon selecting the cosignrequired button for a note in the notes viewing pane, 1501, the cosignnote window 66 is opened. Fields within the cosign note window 66includes note type box indicating the type of note being cosigned, anote text box displaying the note text along with additional informationincluding the author and the data and time the note was filed, andcosign text box allowing the cosigning user to enter text in connectionwith cosigning the note, 1503.

From the link 733 for the print function and the link 741 for the copyfunction, the workflow proceeds to the workflow 1600 illustrated in FIG.16. Upon selecting the copy button for a note from the notes viewingwindow 34, 1601, the text of the note is copied onto a clipboard, suchas the Windows clipboard, 1603. From the clipboard the text may becopied to other notes or may be copied to other applications. Uponselecting the print button for a note from the notes viewing window 34,1605, the text of the selected note is printed through an appropriatelyconfigured printer along with any other information listed with the notein the note viewing window 34, 1607. Types of other information includeauthor and author type.

The invention has been described in terms of several embodiments,including a number of features and functions. Not all features andfunctions are required for every embodiment of the invention, and inthis manner the invention provides a flexible system by which a user maydocument and use clinical patient information. The features discussedherein are intended to be illustrative of those features that may beimplemented; however, such features should not be considered exhaustiveof all possible features that may be implemented in a system configuredin accordance with the embodiments of the invention.

1. A system for documenting patient information from multiple caregiverscomprising: a database for storing free-text patient notes as recordslinked to a patient, different types of caregivers, and timestamps; anda user interface operating in a first mode to display a longitudinalview of the records for a given patient according to timestamp order forall caregivers, and in a second mode to display a longitudinal view ofthe records for a given patient according to timestamp order for asingle caregiver.
 2. A system for documenting patient information frommultiple caregivers comprising: a database for storing free text patientnotes as records linked to a patient and to a first timestamp indicatinga date of writing of the patient record by a given caregiver; and a userinterface operating to select for viewing by the given caregiver patientnotes from multiple caregivers having a first timestamp after a latesttimestamp of a patient record written by the given caregiver.